S Rammelt1, J Winkler, H Zwipp. 1. Klinik und Poliklinik für Unfall- und Wiederherstellungsschirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland, stefan.rammelt@uniklinikum-dresden.de.
Abstract
OBJECTIVE: Anatomic reduction of talar neck and body fractures with axial realignment and restoration of the articular surfaces of the talus. INDICATIONS: Displaced talar neck and body fractures. CONTRAINDICATIONS: High perioperative risk, soft tissue infection, neurogenic osteoarthropathy. SURGICAL TECHNIQUE: Reduction of the axial alignment of the talus and its joints via bilateral approaches according to the preoperative CT-based planning. A medial malleolar osteotomy may be necessary to approach the talar dome. The blood supply via the deltoid ligament and the sinus tarsi has to be respected. Manipulation of the main fragments with K-wires introduced temporarily; a mini-distractor is helpful in restoring the length. Internal fixation is tailored to the individual fracture pattern, including conventional and headless screws, bioresorbable pins, lost K-wires, and/or minifragment plates. Joint transfixation for 6 weeks to ensure ligamentous healing if instability persists after internal fixation. With severe soft tissue damage, temporary tibiometatarsal external fixation is applied until soft tissue consolidation. POSTOPERATIVE MANAGEMENT: Range of motion exercises of the ankle and subtalar joints starting postoperative day 2 except for cases with joint transfixation. Partial weight bearing of 20 kg for 10-12 weeks. Use of a cast or walker for 6 weeks followed by intensive active and passive range of motion exercises of the ankle and subtalar joints. RESULTS: Over 8 years 79 fractures of the talar neck and body were treated. In all, 43 patients with 45 talar neck (n = 30) and body (n = 15) fractures were re-examined clinically and radiologically (mean follow-up 3 years). Definite treatment consisted of open reduction and screw fixation of the talus in 41 cases and small plate fixation in 2 cases supplemented by temporary external fixation for 1-3 weeks in 12 cases. At follow-up, the Maryland Foot Score averaged 86.1 and the AOFAS Ankle/Hindfoot Score averaged 78.9. The Hawkins classification was of prognostic value in talar neck fractures. The functional results and the rate of avascular necrosis (AVN) were unaffected by the time to definite internal fixation. AVN was observed in 11 cases (24%); with only partial AVN involving less than one third of the talar body in 8 of these patients. Due to complete AVN with collapse of the talar dome, 3 patients (6.7%) required fusion. Signs of posttraumatic arthritis of the tibiotalar or subtalar joint were seen in 21 cases (47%). The rate of symptomatic posttraumatic arthritis correlated with the occurrence of total AVN, but not with partial AVN.
OBJECTIVE: Anatomic reduction of talar neck and body fractures with axial realignment and restoration of the articular surfaces of the talus. INDICATIONS: Displaced talar neck and body fractures. CONTRAINDICATIONS: High perioperative risk, soft tissue infection, neurogenic osteoarthropathy. SURGICAL TECHNIQUE: Reduction of the axial alignment of the talus and its joints via bilateral approaches according to the preoperative CT-based planning. A medial malleolar osteotomy may be necessary to approach the talar dome. The blood supply via the deltoid ligament and the sinus tarsi has to be respected. Manipulation of the main fragments with K-wires introduced temporarily; a mini-distractor is helpful in restoring the length. Internal fixation is tailored to the individual fracture pattern, including conventional and headless screws, bioresorbable pins, lost K-wires, and/or minifragment plates. Joint transfixation for 6 weeks to ensure ligamentous healing if instability persists after internal fixation. With severe soft tissue damage, temporary tibiometatarsal external fixation is applied until soft tissue consolidation. POSTOPERATIVE MANAGEMENT: Range of motion exercises of the ankle and subtalar joints starting postoperative day 2 except for cases with joint transfixation. Partial weight bearing of 20 kg for 10-12 weeks. Use of a cast or walker for 6 weeks followed by intensive active and passive range of motion exercises of the ankle and subtalar joints. RESULTS: Over 8 years 79 fractures of the talar neck and body were treated. In all, 43 patients with 45 talar neck (n = 30) and body (n = 15) fractures were re-examined clinically and radiologically (mean follow-up 3 years). Definite treatment consisted of open reduction and screw fixation of the talus in 41 cases and small plate fixation in 2 cases supplemented by temporary external fixation for 1-3 weeks in 12 cases. At follow-up, the Maryland Foot Score averaged 86.1 and the AOFAS Ankle/Hindfoot Score averaged 78.9. The Hawkins classification was of prognostic value in talar neck fractures. The functional results and the rate of avascular necrosis (AVN) were unaffected by the time to definite internal fixation. AVN was observed in 11 cases (24%); with only partial AVN involving less than one third of the talar body in 8 of these patients. Due to complete AVN with collapse of the talar dome, 3 patients (6.7%) required fusion. Signs of posttraumatic arthritis of the tibiotalar or subtalar joint were seen in 21 cases (47%). The rate of symptomatic posttraumatic arthritis correlated with the occurrence of total AVN, but not with partial AVN.